16 Perioperative Management; ERAS

G. Damian Brusko, Karthik Madhavan, and Michael Y. Wang

Summary

Recent implementation of Enhanced Recovery After Surgery (ERAS) pathways in spine surgery have resulted in improved outcomes for patients. These perioperative protocols incorporate several basic and evidence-based principles of enhanced recovery that aim to reduce postoperative narcotics consumption, decrease complications, and shorten length of stay. When ERAS pathways are combined with minimally-invasive spine surgery (MISS) approaches, an even greater benefit may be demonstrated. This chapter discusses the key components of ERAS and how to successfully implement them within an MISS practice.

Henrik Kehlet first described a multimodal pathway for colorectal surgery patients in 1997 that centered around reducing the physiologic response to stress following surgery.1 He postulated that the body’s inflammatory cascade is responsible for pathogenesis of the morbidities associated with major surgery, and concluded that modulation of these mediators could improve recovery. His investigations spawned the development of a multimodal approach for minimizing postoperative recovery time starting from the preoperative period with proper nutrition prior to surgery, progressing to interventions to reduce pain and generalized patient discomfort due to nausea and vomiting, and concluding with exercise regimens to mobilize patients in the early postoperative period.

The most important of the physiologic derangements following surgery is the development of insulin resistance. Catecholamine release and impaired immune function combine to induce a state of insulin resistance that negatively impacts glucose metabolism. Both increased hepatic glucose production and decreased insulin-dependent peripheral uptake lead to hyperglycemia.² The increased levels of circulating glucose are transported into immune cells, neurons, and endothelial cells because glucose transport in these cells is concentration dependent. Accumulation of glucose within the cells is responsible for oxygen radical production, altered gene expression, and inflammation.³ Managing the development of key pathogenic factors, particularly insulin resistance, is paramount to speed up recovery time and improve outcomes. Preoperative optimization of the patient’s health, use of minimally invasive surgical techniques, nonnarcotic pain management, and early mobilization all contribute to reducing the surgical stress response. The core physiologic principles of ERAS are summarized in Fig. 16.1.

More recently, spine surgery has begun to explore the implementation of ERAS principles. An increased demand for major spinal surgery and global variations in length of stay, recovery, and complication rates make spine surgery a solid candidate to benefit from a fast-track recovery protocol.4 Spine surgery is associated with especially high pain levels postoperatively, with lumbar fusions and complex reconstructions rated as three of the top six most painful surgical procedures.⁵ In addition, rising health care costs over the past decade for spine surgeries may potentially be due to the greater number of procedures and increased length of stay.^4,6 Each of these factors demonstrates the utility of an ERAS protocol for spine surgery.

The following sections examine a perioperative approach that spine surgeons may consider for implementation of ERAS. Additional focus is placed on a few specific aspects that can easily be incorporated into a spine surgeon’s daily practice. It should be noted that, at present, no official ERAS guidelines for spine surgery have been published, but there is a growing body of literature suggesting the effectiveness of many of the interventions described below. A sample ERAS protocol adapted from our institution is applicable to many standard spine procedures ranging from one-level decompression to multilevel fusion, as it focuses primarily on the pre- and postoperative components (Fig. 16.2).

16.3.1 Preoperative Preparation

The patient’s journey through ERAS begins at the time of surgical consult in the clinic. ERAS protocols can be applied to all patients undergoing any elective spine surgery, regardless of age or comorbidities. However, during the early implementation phase at our institution, we chose to include all patients undergoing only posterior lumbar fusion procedures (Table 16.1). Once a patient enters the ERAS pathway, expectations regarding the surgery and recovery process must be detailed. The surgeon should describe all aspects of the process, from preoperative preparations to the recovery process and early discharge. Surgeons must assess the patient’s current health status and develop a plan for optimization of health before surgery. Patients should be educated on smoking and alcohol cessation for 30 days prior to surgery and advised to walk for 30 minutes each day. In addition to lifestyle modifications aimed at improving physical health status, patients must be prepared mentally for each aspect of surgery. This includes reducing fear and anxiety about surgical and anesthetic procedures and preparing patients for a decreased hospital stay. Patients should understand that recovery only happens with their participation in the protocol. Both physical and mental preparations prior to surgery, in combination with preadmission discharge planning, are the essential first steps in an efficacious ERAS pathway.

Table 16.1 Sample ERAS inclusion and exclusion criteria for posterior lumbar instrumented fusion

Another essential component of ERAS is perioperative, goal-directed fluid management, which prevents hypotension and maintains adequate oxygen delivery to tissues. Hydration with a clear carbohydrate drink up to 2 hours before surgery is recommended to reduce gluconeogenesis, prevent insulin resistance, and limit anxiety. This practice is also supported by the current American Society of Anesthesiologists guidelines on preoperative fasting.⁷ During surgery, the body’s natural reaction to blood loss is to conserve sodium and consequently water via activation of the renin–angiotensin–aldosterone system. However, the body is more efficient at conservation of sodium compared to elimination. Therefore, intravenous (IV) infusion of lactated Ringer’s solution, blood loss, and urine output during surgery should all be maintained in a balanced 1:1 ratio, optimizing volume status and preventing common surgical complications.⁸ Maintenance of volume status is the key; an association with weight gain of 5 lb or more has been shown to lengthen hospital stay and increase complications, thus directly opposing the core principles of ERAS.⁹

16.3.2 Intraoperative Technique

Specific surgical techniques are directed based on the diagnosis and surgeon preference, but within ERAS, should utilize minimally invasive approaches, many of which are described in this book. There are, however, important intraoperative aspects that are unique to ERAS, including awake anesthesia, percutaneous screws, and use of a long-acting local anesthetic that have previously been described for endoscopic minimally invasive spine transforaminal lateral interbody fusion (MIS TLIF).10 Awake anesthesia reduces both postoperative stress and memory loss. Injection of a long-acting sodium blocker, specifically liposomal bupivacaine, along the pedicle screw tracts before screw insertion is recommended. The use of liposomal bupivacaine has been shown to reduce postoperative narcotic consumption and length of stay in patients undergoing TLIF.^10,11 Future development of similar ultra-minimally invasive surgical procedures will likely increase the feasibility of incorporating ERAS into spine surgery.

16.3.3 Postoperative Management

The key aspects of postoperative management within ERAS include nonnarcotic pain control, prevention of ileus and nausea, and early mobilization. Patients are given oral acetaminophen prior to surgery and IV acetaminophen for pain control immediately following surgery. This strays from the traditional paradigm of patient-controlled analgesia with opioids and instead only supplies narcotics on an “as needed” basis. Our institution has recently implemented a similar analgesic protocol for an awake MIS TLIF described above. Early results have demonstrated significant reductions in average total daily narcotic usage on postoperative days 0 and 1, and overall narcotic usage as compared with conventional MIS TLIF, with additional reductions in length of stay, operative time, and blood loss. The 72-hour duration of liposomal bupivacaine combined with IV acetaminophen in the early postoperative period should provide adequate pain relief for patients, obviating the need for opioids and enabling the next essential phase in the enhanced recovery process—early mobilization.

Fear of movement following surgery, both pre- and postoperatively, is associated with increased pain and disability and overall poorer quality of life scores, thus highlighting the importance of early mobilization.^12,13 The combination of prehabilitation and early rehabilitation programs, with optimized multimodal elements of intense mobilization the day of surgery, analgesic control, and enteral nutrition, resulted in reduced morbidity, length of stay, pain, and increased patient satisfaction.^14,15 Such interventions aim to assuage patients’ fears about poor postoperative mobility and ready them for an earlier discharge from the hospital.

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IV MISS Techniques Surgical Tips, Tricks, and Techniques to Minimize Invasiveness; General Advice on How to Handle Fluoroscopy, Blood Loss, and Infection Rates Thoracic Vertebroplasty and Kyphoplasty Lateral Retropleural Thoracic Discectomy and Corpectomy Posterior Cervical Facet Cages DTRAX MIS-TLIF with Total Navigation and Expandable Interbody Cages

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